1. RED FLAGS IN HEADACHE; A HEADACHE FOR THE MAU DOCTOR FAYYAZ AHMED FAYYAZ AHMED CONSULTANT NEUROLOGIST HULL & EAST YORKSHIRE HOSPITALS NHS TRUST

2. Objectives Recognising red flags in Headache Recognising red flags in Headache Clinical Features of Serious Headache Disorders Clinical Features of Serious Headache Disorders Investigation plan and further referral Investigation plan and further referral

4. HEADACHES One of the commonest symptom One of the commonest symptom Account for 30% GP and 50% Neurology Referrals Account for 30% GP and 50% Neurology Referrals 95% of the population at some stage experience headaches 95% of the population at some stage experience headaches 15-19% of Acute Medical Admissions (1), 55% of Neurology in A & E (2) 15-19% of Acute Medical Admissions (1), 55% of Neurology in A & E (2) 1. Weatherall M., J RCP Edinb 2006; 36: 196-200 2. Craig J., Patterson V., Roche L., JamisonJ., Accident and Emergency Neurology: time for a reappraisal? Health Trends, 1997, 29, 89-91

5. DILEMMA IN MAU/A&E

6. DILEMMA IN MAU/AE AM I DEALING WITH A SERIOUS HEADACHE ? AM I DEALING WITH A SERIOUS HEADACHE ? DO I URGENTLY INVESTIGATE OR ASK FOR HELP NOW OR AS AN OP ? DO I URGENTLY INVESTIGATE OR ASK FOR HELP NOW OR AS AN OP ? WHO DO I ASK FOR HELP; NEUROLOGIST OR NEUROSURGEON? WHO DO I ASK FOR HELP; NEUROLOGIST OR NEUROSURGEON? AM I OK TO SEND THIS PATIENT HOME? AM I OK TO SEND THIS PATIENT HOME?

7. SERIOUS HEADACHES Subarachnoid Haemorrhage Brain Tumours or Space Occupying Lesion (SOL) Infections like Meningitis, Encephalitis Temporal arteritis

8. RECOGNISE SERIOUS HEADACHES RED FLAG HEADACHES Hyperacute onset no previous history Gradually progressive no previous history Presence of any neurological signs Headaches above the age of 60 Change in characteristics or pattern

9. NON URGENT HEADACHES Round the Clock for > 3 months Round the Clock for > 3 months No Neurological Signs No Neurological Signs Acute Exacerbations of Known Migraines Acute Exacerbations of Known Migraines Episodic Headaches > 6 months with clear headache free intervals Episodic Headaches > 6 months with clear headache free intervals

10. Thunderclap Headache (TCH) Peaks within a minute Peaks within a minute Primary and Secondary (Clinically cannot differentiate) 1 Primary and Secondary (Clinically cannot differentiate) 1 Primary TCH – Diagnosis of exclusion Primary TCH – Diagnosis of exclusion SAH – CT/LP earlier or CTA later SAH – CT/LP earlier or CTA later Arterial Dissection – Focal Neurological signs Arterial Dissection – Focal Neurological signs Pituitary Apoplexy – CT/MRI abnormal Pituitary Apoplexy – CT/MRI abnormal Venous Sinus Thrombosis – Raised CSF, CTV Venous Sinus Thrombosis – Raised CSF, CTV Spontaneous Intracranial Hypotension –Typical history Spontaneous Intracranial Hypotension –Typical history 1. Linn et al JNNP 1998:65; 791-3

11. SAH 11 per 100,000 11 per 100,000 85% Saccular Aneurysm, 10% perimensephalic 5% AVM 85% Saccular Aneurysm, 10% perimensephalic 5% AVM Peaks within a minute and last at least an hour Peaks within a minute and last at least an hour Worst Ever Worst Ever May be associated with LOC May be associated with LOC NV Photo/phonophobia NV Photo/phonophobia Neck Rigidity, Kernig’s sign Neck Rigidity, Kernig’s sign

12. SAH CT scan Sensitivity 1 CT scan Sensitivity 1 97% within 12 hours 97% within 12 hours 85% after 24 hours 85% after 24 hours 76% after 48 hours 76% after 48 hours 58% after 5 days 58% after 5 days LP Xanthocromia LP Xanthocromia 100% 12 hrs – 2 weeks 100% 12 hrs – 2 weeks 70% week 3 70% week 3 40% week 4 40% week 4 1. Van der Wee et al JNNP 1995

14. SAH – MISDIAGNOSIS Reasons 1 Reasons 1 The diagnosis was not considered The diagnosis was not considered Failure to understand limitations of CT Failure to understand limitations of CT Failure to properly perform / analyse CSF Failure to properly perform / analyse CSF Wrong investigation – MRI/MRA Wrong investigation – MRI/MRA 1 in 20 SAH patients are missed in A & E 2 1 in 20 SAH patients are missed in A & E 2 1. NEGM 2000, 342; 29-36 2. Stroke 2007, 38; 1216

15. SAH - MISDIAGNOSIS Instantaneous headaches only in 50% Instantaneous headaches only in 50% 1 in 6 SAH may present with a fit 1 in 6 SAH may present with a fit 1-2% present with acute confusion 1-2% present with acute confusion LP is traumatic LP is traumatic Focusing on hypertension and arrhythmia Focusing on hypertension and arrhythmia

16. RECENT AND PROGRESSIVE HEADACHES weeks to < 3/12 EXCLUDE EXCLUDE SOL SOL Cerebral Venous Sinus Thrombosis Cerebral Venous Sinus Thrombosis Idiopathic Intracranial Hypertension Idiopathic Intracranial Hypertension > 55 Consider Temporal Arteritis > 55 Consider Temporal Arteritis NEW DAILY PERSISTENT HEADACHES NEW DAILY PERSISTENT HEADACHES Diagnosis of exclusion Diagnosis of exclusion Daily unremitting from onset Daily unremitting from onset Migrainous or TTH Migrainous or TTH

17. SYMPTOMS of Raised ICP Headaches worse on straining and Early Morning Headaches worse on straining and Early Morning Nausea and Vomiting Nausea and Vomiting Drowsiness Drowsiness Visual Symptoms Visual Symptoms Seizures Seizures

18. SIGNS of Raised ICP Impairment in Conscious Level (GCS<15) Impairment in Conscious Level (GCS<15) Papilloedema Papilloedema Hypertension Hypertension Bradycardia Bradycardia False localising signs such as VI N palsy False localising signs such as VI N palsy Focal Neurological Signs Focal Neurological Signs

20. CT Meningioma

21. G.B.M

22. Cerebral Metastasis

23. Cerebral Venous Thrombosis Cerebral Venous Thrombosis Female, Smoker, OCP, Postpartum Female, Smoker, OCP, Postpartum Dehydration, Hyperviscosity Dehydration, Hyperviscosity Drowsy, Seizures, Focal Signs Drowsy, Seizures, Focal Signs

24. Cerebral Venous Thrombosis Clinical Suspicion Clinical Suspicion CT Venogram/MRA CT Venogram/MRA Anticoagulation Anticoagulation

26. Benign Intracranial Hypertension Female, Overweight, Smoker, OCP Female, Overweight, Smoker, OCP Visual Symptoms Visual Symptoms Papilloedema Papilloedema

27. Benign Intracranial Hypertension Clinical Suspicion Clinical Suspicion CT/MRI MRA CT/MRI MRA Lumbar Puncture Lumbar Puncture Acetazolamide/Topiramate/Diuretic Acetazolamide/Topiramate/Diuretic

28. TEMPORAL ARTERITIS; Features Uncommon below the age of 55 Uncommon below the age of 55 Women twice as much as Men Women twice as much as Men Common in British / Scandinavian Common in British / Scandinavian Fairly Uncommon in Asian/Africans Fairly Uncommon in Asian/Africans Bengtsson B-A, Malmvall BE. Giant Cell Arteritis, Acta Med Scand, 1982;658:1-102

29. TEMPORAL ARTERITIS; Symptoms Recent onset on uni or bilateral temporal Headaches Recent onset on uni or bilateral temporal Headaches Cutaneous Allodynia Cutaneous Allodynia Jaw Claudication Jaw Claudication Systemic Symptoms Systemic Symptoms Pain and aching in Shoulder/Pelvic girdle muscles Pain and aching in Shoulder/Pelvic girdle muscles

30. TEMPORAL ARTERITIS; Diagnosis Clinical Suspicion Clinical Suspicion ESR/PV and CRP Normal < 1% ESR/PV and CRP Normal < 1% Temporal Artery Biopsy – Controversial Temporal Artery Biopsy – Controversial Steroids Steroids Hayreh SS, Podhajsky PA, Raman RI. Giant Cell Arteritis; Validity and Reliability of various diagnostic criteria. Am j Ophthalmol 1997;123:285-296.

32. FEBRILE HEADACHES; DAYS Meningitis – Viral, Bacterial Meningitis – Viral, Bacterial Encephalitis Encephalitis

33. ENCEPHALITIS: Symptoms/Signs Headaches and altered conscious level Headaches and altered conscious level Seizures Seizures Focal Signs Focal Signs

34. ENCEPHALITIS: Diagnosis CT/MRI (Diffuse or Focal Oedema) CT/MRI (Diffuse or Focal Oedema) EEG (Slow waves over affected area) EEG (Slow waves over affected area) CSF (Lymphocytes) PCR positive for HSV-1,VZV CSF (Lymphocytes) PCR positive for HSV-1,VZV Acyclovir Acyclovir

35. Headache that Needs Urgent Imaging BASH guidelines Clinical signs present Clinical signs present Pronounced signs of raised intracranial pressure Pronounced signs of raised intracranial pressure Change in cognitive functional personality Change in cognitive functional personality Relevant systemic disease Relevant systemic disease Worst headache ever particularly if crescendo is reached in minutes or rapidly deteriorating Worst headache ever particularly if crescendo is reached in minutes or rapidly deteriorating

36. SUMMARY Serious Causes are Uncommon Serious Causes are Uncommon SAH, Meningitis, Encephalitis SOL and TA are the main serious headaches SAH, Meningitis, Encephalitis SOL and TA are the main serious headaches Refer to Neurosurgeon (SAH) or Neurologists when in doubt Refer to Neurosurgeon (SAH) or Neurologists when in doubt

37. JOIN Special rates for Trainees/Nurses/Therapists Special rates for Trainees/Nurses/Therapists Electronic or Paper copies of Cephalalgia Electronic or Paper copies of Cephalalgia Invitation to BASH meetings Invitation to BASH meetings BASH NEWSLETTER (www.bash.org.uk) BASH NEWSLETTER (www.bash.org.uk)

38. BASH MEETINGS IN 2011/12 GLASGOW JUNE 15-162011 GLASGOW JUNE 15-162011 PLYMOUTHOCTOBER 2011 PLYMOUTHOCTOBER 2011 LONDONAPRIL2012 LONDONAPRIL2012 KEELESEPTEMBER 2012 KEELESEPTEMBER 2012 Contact Debbie.Buttle@hey.nhs.uk Contact Debbie.Buttle@hey.nhs.ukDebbie.Buttle@hey.nhs.uk